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Note To Clinicians From A Psychiatrist Practicing Neurofeedback

Dr. Pesaniello is in private practice in Chincoteague, VA. She received her medical and psychiatric training at Johns Hopkins Medical School in Baltimore, MD. She has no conflict of interest with regard to receiving any compensation from pharmaceutical companies or companies that offer neurofeedback training or equipment. She did serve as faculty recently at the American Psychiatric Association Convention in Washington, DC, where she presented one of her cases who received neurofeedback. (She practices individual and group psychotherapy in addition to medication management in her practice of psychiatry.)

“I’ve been a practicing psychiatrist for 15 years. Two years ago, I added neurofeedback to my practice. It is important to me to do what I can to inform other psychiatrists and mental health clinicians of my experience. It is becoming increasingly clear to me that neurofeedback — if available in your area — should be on your list of interventions to consider.

The reason I pursued training in neurofeedback was my awareness of the limitations of the medications we rely on for treatment. Despite the medications we use, there is a high level of treatment resistance in mood disorders, as well a high degree of residual symptoms, a high degree of dropout, and problematic side effects very likely with certain medications.

There is no disagreement among psychiatrists that our attempts to help patients with medications are limited by such things as sexual side effects with SSRI’s, and cognitive and emotional dulling with mood stabilizers, not to mention actual end-organ effects such as on the kidney and thyroid with lithium, and negative nervous system effects with the neuroleptics. And even when the medications do help, it is often not enough, and with side effects so noxious that we end up with treatment noncompliance limiting the effect of the medications. And with all this, the medications treat symptomatically, and offer little in the way of cure.

I found it incomprehensible initially when I heard that social workers in the area were teaching patients to stay asleep with a form of biofeedback — training brain waves, then “moving on” to mood regulation…..And using a method that patients learned to maintain on their own, reduced their medications, and felt and functioned better than when they were on meds and therapy alone! I explored further via the internet and phone, and communicated with the few psychiatrists who I could find were doing neurofeedback. Within months I took the initial training, mainly to learn more about neurofeedback. By the end of the training I was convinced, purchased the computer equipment, and began working on my initial patients…And now I am learning the power of this modality. Just like learning psychopharmacology skills and psychotherapy skills — learning more and refining the art and science of using neurofeedback will involve ongoing diligence and learning from the “masters”. However, I’ve been delighted that my young skills in using neurofeedback are already effective for some of my suffering patients.

Neurofeedback offers a powerful intervention. While not a panacea, it can improve and stabilize symptoms in the very kinds of cases psychiatrists struggle with.

My initial patients were bipolar patients. One was a mentally disabled nurse in her 60’s who had over 20years of chronic depression and hypomanias, mostly withdrawn to her home. She was on two anticonvulsants and two antidepressants. Within 6 sessions of neurofeedback, she felt much better. By 16 sessions, most of her most troublesome emotional symptoms were “gone”, as well as her daily headaches (diagnosed migraine). This despite her resistance to treating her sleep apnea. Now, a year later she is on one mood stabilizer.

The other bipolar patient responded rapidly as well. He was a recovering alcoholic in his 50’s. He was on one mood stabilizer and an antidepressant. Despite a complex personal history including psychotic symptoms and several psychiatric admissions as a teenager, and gut-wrenching anxiety….and chronic depression and closed head trauma, his anxiety improved quickly and his depressed mood improved. We were able to discontinue his antidepressants, now for over a year and a half.

Both of these patients have continued in neurofeedback. The first has tapered to one session every two weeks, sometimes goes a month. The other is still in weekly sessions as we have been trying additional placements /sites to see if we can help with some cognitive processing issues of long-standing. Both of these patients have had periods of missing sessions because of vacations, etc, and still maintained their improvement. Both of them were trained along the sensor motor strip, at C5-C6 (interhemispheric placements, rewarding SMR beta and inhibiting theta and high beta).

Another exciting response was in a middle-aged teacher who had chronic sleep maintenance problems. (He awakened after two or three hours of sleep and if he slept after that, he only slept lightly). And he had chronic depressions that had broken through SSRI’s and Wellbutrin max doses — both of which incidentally caused sexual side effects. I trained this man along the sensor-motor strip with unilateral placements at C3 and at C4 initially rewarding SMR beta and inhibiting theta and high beta. Then we moved forward and treated the left frontal area (F3, training him to inhibit alpha intrusion), and at the same time treated the right parietal area, increasing alpha, which often helps with body tension and social anxiety. His improvement was initially with better energy and less anxiety — and improved alertness, which he initially had not complained of. By 30 sessions, he knew he was sleeping better. He was in remission of his depressive and sleep symptoms after 40 sessions. He had discontinued all sleep medication early in treatment, and after maintaining his improvement for several months after that, he chose to go off antidepressants. He was sleeping deeply and restoratively through the night and in remission of all depressive symptoms. He had some slipping of his improvement around eight months out and two other times, several months apart. He noted some fatigue and less deep sleep, which has responded well each time to one or two “refresher sessions”. He in particular noted improvement in his social anxiety (probably from the left parietal tx) as an added benefit of treatment. He has not needed further antidepressants now for over a year and a half. This receiving no treatment at all (no therapy).

I have a practice with relatively high functioning patients, low acuity. However, as I have listened to the experiences of other practitioners, I am hearing of very good results in more ill bipolar and depressed patients. I am excited and eager to encourage other psychiatrists to consider the value of this modality for patients who need more solutions, who are not responding adequately to medications, do not tolerate medications well, or want to reduce their meds. In particular this may have great utility for bipolar women who are planning pregnancy, especially if they plan to discontinue their medications. Neurofeedback is safe, and particularly effective with classic bipolar patients. Sleep disorder clinics would do well to invest in neurofeedback. I have seen it help several patients with sleep apnea….with improved alertness and less fatigue, even prior to their starting C-Pap. I had one patient — complex patient with PTSD , depression, migraines and untreated sleep apnea — whose migraines disappeared , anxiety lessened, and whose filing speed at work improved dramatically, when the neurofeedback was the only thing we changed at the time….prior to her starting C-Pap.

Because it addresses brain processing and brain regulation, neurofeedback has wide applications. I think of it as being like an anticonvulsant because of its stabilizing and wide-ranging effects.

I do not treat children, but I do see lots of ADD symptoms in the adults I treat for affective disorder. Neurofeedback has some of its best evidence in treatment of ADHD. In one of the studies it performed as well as Ritalin, AND the improvement was still present after the treatment was discontinued. Some of my mood-disorder patients have seen improvements in their attention and concentration as a result of the neurofeedback we have done for their sleep or mood.

It is very important that psychiatrists know of the availability of neurofeedback, and learn to refer patients to neurofeeback providers and coordinate care with them so patients can get optimum symptom relief on as little meds as possible. I believe it will be cost-effective for psychiatrists to offer the funding to train clinicians working with them, as well. At least one insurance company has been willing to authorize neurofeedback for payment. Once the insurance companies realize its efficacy, I think they will come on board, because it will reduce relapse rates and hospitalizations and length of treatment.

Basics of neurofeedback training can be learned from a four day introductory course and some via-phone supervision as the clinician works with initial patients. The learning curve to feeling comfortable with the assessment, protocol selection and technology is steep, but not unmanageable for me, a part-time practitioner and wife and mother with lots of other interests. There are a few protocols that help lots of people…..and lots of variations, for practitioners who want to explore further. Ongoing training and mentoring are available and considered necessary by most in the field. The research is promosing, and NIMH has become interested. Larger scale studies are underway.

If you do want to refer a patient, check the websites listed below, and make sure the clinician is offering the trainings on FDA-approved equipment, and that they have a license to practice in the appropriate mental health field.”